<%-- 
    Document   : TestTicket
    Created on : Mar 18, 2013, 9:20:40 PM
    Author     : mudassar
--%>

<%@page contentType="text/html" pageEncoding="UTF-8"%>
<!DOCTYPE html>
<%@include file="../common/script.jsp" %>
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<html>
    <head>
        <meta http-equiv="Content-Type" content="text/html; charset=UTF-8">
        <%@include file="../common/title.jsp" %>
        <script type="text/javascript">
            $(function() {
                $( "#accordion" ).accordion();
            });
        </script>
    </head>
    <body>
        <%@include file="../common/header.jsp" %>
        <%@include file="../common/menu.jsp" %>
        <div id="accordion" style="padding-top: 100px;padding-left: 40px;padding-right: 40px;padding-bottom: 20px">
            <h3>Customer Information</h3>
            <div>
                <table class="formTable1">

                    <tr>
                        <td><spring:message code="patientName"/>:<br/><form:input path="customerName" cssClass="userInputLarge"/></td>  
                        <td>
                            <spring:message code="activeForCustomer"/>:<br/>
                            <form:radiobutton cssClass="gender" path="active" value="true" cssStyle="margin:0 -20px 0 0;" /><spring:message code="yes"/>&nbsp;
                            <form:radiobutton cssClass="gender" path="active" value="false" cssStyle="margin:0 -20px 0 0;" /><spring:message code="no"/>
                        </td>

                        <td><spring:message code="important"/>:<br/>
                            <form:radiobutton cssClass="gender" path="important" value="true" cssStyle="margin:0 -20px 0 0;" /><spring:message code="yes"/>&nbsp;
                            <form:radiobutton cssClass="gender" path="important" value="false" cssStyle="margin:0 -20px 0 0;" /><spring:message code="no"/>
                        </td>
                        <td colspan="2"><spring:message code="remainInContactVia"/>:<br/>
                            <form:checkbox path="sms" value="true" label="Sms" cssStyle="margin:0 -20px 0 0;"></form:checkbox>
                            <form:checkbox path="email" value="true" label="Email" cssStyle="margin:0 -20px 0 0;"></form:checkbox>
                            </td>
                        </tr>
                        <tr>
                            <td><spring:message code="mrNo"/>:<br/>
                            <form:input path="mrNo" cssClass="userInputLarge"/></td>
                        <td><spring:message code="empId"/>:<br/>
                            <form:input path="empId" cssClass="userInputLarge disableinput" readonly="true" /></td><br/>
                    <br><span id="errorsDiv_empId"></span>



                    <td><spring:message code="familyCode"/>:<br/><form:input path="familyCode" cssClass="userInputLarge"/></td>
                    <td>
                        <spring:message code="eligible"/>:<br/>
                        <form:radiobutton cssClass="gender" path="eligible" value="true" cssStyle="margin:0 -20px 0 0;" /><spring:message code="yes"/>&nbsp;
                        <form:radiobutton cssClass="gender" path="eligible" value="false" cssStyle="margin:0 -20px 0 0;" /><spring:message code="no"/>
                    </td>
                    </tr>
                    <tr>
                        <td><spring:message code="phone1"/>:<br/><form:input path="phone1" cssClass="userInputLarge" id="phone1" />
                            <span id="errorsDiv_phone1"></span><br/>
                        </td>
                        <td><spring:message code="phone2"/>:<br/><form:input path="phone2" cssClass="userInputLarge"/></td> 
                    <span id="errorsDiv_phone2"></span><br/>

                    <td><spring:message code="emailId"/>:<br/><form:input  path="emailId"  class="userInputLarge"/><br/>
                        <span id="errorsDiv_emailId"></span><br/>
                    </td>
                    <td><spring:message code="customerType"/>:<br/>
                        <form:select  path="paymentTypeId.paymentTypeId"  id="paymentTypeId.paymentTypeId" cssClass="userInputMedium">
                            <form:option value="" label="-"></form:option>
                            <form:options items="${paymentTypeList}" itemLabel="paymentTypeName" itemValue="paymentTypeId"></form:options>
                        </form:select><br/>
                        <span id="errorsDiv_paymentTypeId.paymentTypeId"></span><br/>
                    </td>
                    </tr>
                    <tr>
                        <td><spring:message code="dateOfBirth"/>:<br/>
                            <input name="dateOfBirth1"  id="dateOfBirth1" value="${customer.dateOfBirth}" class="userInputLarge" />
                        </td>
                        <%--<td><spring:message code="age"/>:<br/>
                            <form:input path="age" cssClass="userInputLarge"/> 
                            <input type="text" readonly="true" name="age" id="age">
                            <br><span id="errorsDiv_age"></span>
                        </td>--%>

                        <td>
                            <spring:message code="gender"/>:<br/>
                            <form:select  path="gender"  cssClass="userInputMedium">
                                <form:option value="" label="-"></form:option>
                                <form:option value="Male" label="-">Male</form:option>
                                <form:option value="Female" label="-">Female</form:option>
                                <form:option value="U" label="-">U</form:option>
                                <form:option value="Not Known" label="-">Not Known</form:option>
                            </form:select><br/>
                            <span id="errorsDiv_gender"></span><br/>
                        </td>
                        <td>
                            <spring:message code="bloodGroup"/>:<br/>
                            <form:select  path="bloodGroup"  cssClass="userInputMedium">
                                <form:option value="" label="-"></form:option>
                                <form:option value="A+" label="-">A+</form:option>
                                <form:option value="A-" label="-">A-</form:option>
                                <form:option value="B+" label="-">B+</form:option>
                                <form:option value="B-" label="-">B-</form:option>
                                <form:option value="AB+" label="-">AB+</form:option>
                                <form:option value="AB-" label="-">AB-</form:option>
                                <form:option value="O+" label="-">O+</form:option>
                                <form:option value="O-" label="-">O-</form:option>
                                <form:option value="Not Known" label="-">Not Known</form:option>
                            </form:select><br/>
                            <span id="errorsDiv_bloodGroup"></span><br/>
                        </td>

                    </tr>

                    <tr>
                        <td><spring:message code="relation"/>:<br/> <form:select  path="relation.relationId"  cssClass="userInputMedium">
                                <form:option value="" label="-"></form:option>
                                <form:options items="${relationList}" itemLabel="relationName" itemValue="relationId"></form:options>
                            </form:select><br/>
                            <span id="errorsDiv_relation.relationId"></span><br/>
                        </td>
                        <td>
                            <spring:message code="noOfDependence"/>:<br/>
                            <%--<form:input path="dependence" cssClass="userInputMedium"/> --%>
                            <form:select  path="dependence" id="dependence" cssClass="userInputMedium">
                                <form:option value="0" label="-">0</form:option>
                                <form:option value="1" label="-">1</form:option>
                                <form:option value="2" label="-">2</form:option>
                                <form:option value="3" label="-">3</form:option>
                                <form:option value="4" label="-">4</form:option>
                                <form:option value="5" label="-">5</form:option>
                                <form:option value="6" label="-">6</form:option>
                                <form:option value="7" label="-">7</form:option>
                                <form:option value="8" label="-">8</form:option>
                                <form:option value="9" label="-">9</form:option>
                                <form:option value="N/A" label="-">N/A</form:option>
                            </form:select>
                        </td>


                        <td><spring:message code="dateOfJoining"/>:<br/>
                            <input name="dateOfJoining1"  id="dateOfJoining1" value="${customer.dateOfJoining}" class="userInputLarge"/>
                        </td>
                        <td>
                            <spring:message code="officeLocation"/>:<br/>

                            <form:select  path="officeLocation.officeId" id="officeLocation.officeId" cssClass="userInputLarge">
                                <form:option value="" label="-"></form:option>
                                <form:options items="${officeList}" itemLabel="officeLocation" itemValue="officeId" ></form:options>
                            </form:select><br/>
                            <span id="errorsDiv_officeLocation.officeId"></span><br/>
                        </td>


                    </tr>

                    <tr>
                        <td><spring:message code="address1"/>:<br/><form:textarea path="address" cssClass="userInputLarge"/></td>
                        <td><spring:message code="address2"/>:<br/><form:textarea path="road" cssClass="userInputLarge"/></td>
                    </tr>
                    <tr>
                        <td><spring:message code="landmark"/>:<br/><form:input path="landmark" cssClass="userInputLarge"/></td>
                    </tr>
                    <tr>
                        <td>
                            <spring:message code="pinCode"/>:<br/>
                            <form:input path="zipCodeArea.zipCode" cssClass="userInputMedium" onchange="showZipCode();" /><br/>
                            <span id="errorsDiv_zipCodeArea.zipCode"></span><br/></td>

                    </tr>
                    <tr>
                        <td>Area :<br/>
                            <input type="text" name="area" id="area" value="${customer.zipCodeArea.area}" class="userInputLargeReadOnly" readonly >
                        </td>
                        <td>MasterZone :<br/>
                            <input type="text" name="masterZone" id="masterZone" value="${customer.zipCodeArea.masterZone.masterZoneCode}" class="userInputMediumReadOnly" readonly  >
                        </td>
                    </tr>

                    <tr>

                        <td><spring:message code="prefferdCenter"/>:<br/>
                            <form:select  path="healthSpringCenter.centerId"  id="healthSpringCenter.centerId" cssClass="userInputMedium">
                                <form:option value="" label="-"></form:option>
                                <form:options items="${centerList}" itemLabel="centerName" itemValue="centerId"></form:options>
                            </form:select><br/>
                            <span id="errorsDiv_healthSpringCenter.centerId"></span><br/>
                        </td>
                        <td><spring:message code="registrationStatus"/>:<br/>
                            <form:select  path="registrationStatus"  cssClass="userInputMedium">
                                <form:option value="Not Started" label="-">Not Started</form:option>
                                <form:option value="Pending" label="-">Pending</form:option>
                                <form:option value="Completed" label="-">Completed</form:option>
                            </form:select><br/>
                        </td>
                    </tr>

                    <tr>

                        <td>Customer Inputs:<br/> 
                            <form:textarea path="notes" cssClass="userInputLarge" readonly="true"/><br/>
                        </td>
                    </tr>

                </table>
            </div>
            <h3>Open Ticket</h3>
            <div>
                <p>
                    Sed non urna. Donec et ante. Phasellus eu ligula. Vestibulum sit amet
                    purus. Vivamus hendrerit, dolor at aliquet laoreet, mauris turpis porttitor
                    velit, faucibus interdum tellus libero ac justo. Vivamus non quam. In
                    suscipit faucibus urna.
                </p>
            </div>
            <h3>Closed Ticket</h3>
            <div>
                <p>
                    Nam enim risus, molestie et, porta ac, aliquam ac, risus. Quisque lobortis.
                    Phasellus pellentesque purus in massa. Aenean in pede. Phasellus ac libero
                    ac tellus pellentesque semper. Sed ac felis. Sed commodo, magna quis
                    lacinia ornare, quam ante aliquam nisi, eu iaculis leo purus venenatis dui.
                </p>
                <ul>
                    <li>List item one</li>
                    <li>List item two</li>
                    <li>List item three</li>
                </ul>
            </div>

        </div>
    </body>
</html>
